2013 KAHCF Spring Education Conference Session #16 Wound Management - Food for Thought Speaker: Chuck Gokoo 4/17/2013 KBN: 5-0002-707-049-1217
2013 KAHCF Spring Education Conference
Session #16
Wound Management - Food for Thought
Speaker: Chuck Gokoo
4/17/2013
KBN: 5-0002-707-049-1217
3/8/2013
1
As a courtesy to those around you, please
silence your cell phone and other
electronic devices.
Thank you for your cooperation.
1© 2013 AMT Education Division
Wound Healing
Food for ThoughtChuck Gokoo MD, CWS
Chief Medical Officer
American Medical Technologies
2© 2013 AMT Education Division
2013 KAHCF Spring Education Conference
Session #16
Wound Management - Food for Thought
Speaker: Chuck Gokoo
4/17/2013
KBN: 5-0002-707-049-1217
3/8/2013
2
Disclaimer
The information presented herein is provided for the general well-being
and benefit of the public, and is for educational and informational
purposes only . It is for the attendees’ general knowledge and is not a
substitute for legal or medical advice. Although every effort has been
made to provide accurate information herein, laws change frequently and
vary from state to state.
The material provided herein is not comprehensive for all legal and
medical developments and may contain errors or omissions. If you need
advice regarding a specific medical or legal situation, please consult a
medical or legal professional. Gordian Medical, Inc. dba American
Medical Technologies shall not be liable for any errors or omissions in this
information.
3© 2013 AMT Education Division
Program Overview and Objectives
© 2013 AMT Education Division4
Discuss the role of dehydration and malnutrition impeding wound healing
Discuss barriers impeding wound
Explain the role specific vitamins and minerals play in the wound healing process
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Hydration and Nutrition
Nursing Homes
≥500,000 residents may suffer from malnutrition or dehydration
50% of residents needs help with eating
21% are completely staff dependent for eating
50% - 75% of nursing home residents have dysphagia
52% of hospital patients admitted with a diagnosis of dehydration will
come from a nursing home
Between 1999 and 2002, 13,890 nursing home patients nationwide died
from malnutrition and dehydration contributed to the deaths of about
68,000 others
$6.5 million awarded to a Ohio widow
-Nursing home lawsuit filed over the dehydration death of her husband allegedly caused
when he was not provided with enough water during a temporary nursing home stay
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Wound Management
Transdisciplinary Team
Nursing Home Administration, Medical
Director, DON/ADON
-CNA, RD, MD, Nursing Staff, Pharmacists, NP, PT, OT,
MDS Coordinator, Case Manager, Social Service,
Hospice
-Care planning reflective of concerns identified in the
at-risk resident assessment protocol
-Past Hx of hydration and eating patterns and weights
-Clarify hydration and nutritional issues, needs and
goals in context to the resident's overall condition
-Input of the resident and family members
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Wound Management
Barriers to Healing
Lack of knowledge
Aging
Peripheral Vascular Disease
Nutrition deficiency
Infection
Stress
Tumors
Metabolic disorders
Impaired Immunity
Medications
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Wound Management
Skin breakdown
-Visible evidence of a general catabolic state
-Fight or flight (stress hormones)
-Suppression of the synthesis of protein, glycogen, triglycerides
-Protein energy malnutrition (PEM)
A resident with a PrU who continues to lose weight needs:
-Additional caloric intake
-Correction (where possible) of conditions that are creating a hypermetabolic state
Consult a registered dietician or nutritionist
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Wound Management
Registered Dietician(RD)
Resident Nutrition
-Assessment
-Diagnosis
-Intervention
-Monitoring
-Evaluation
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Wound Management
RD Assessment
Diet and intake history
Weight history
-Regular weighing
Physical examination
-Skin assessment
Hydration, nutritional diagnosis
-Co morbidities (e. g. diabetes)
Estimation of hydration, nutrient requirements
Hydration, nutritional PoC
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Wound Management
Hydration
Water
-Approximately 72% of nonfat weight
-Keeps the skin moist
-Protects from tearing and abrasions
-Plays a role in moving nutrients to the ulcer
bed to promote new tissue growth
-Assists in removing waste away from the ulcer
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Wound Management
Exudate (Type)
Inflammatory
-Serous - watery plasma, thin, clear or light color
-Serosanguineous - plasma and red blood cells, thin, light red to pink
-Sanguineous - thin, red, bloody
Infection
-Seropurulent - contains some white blood cells and living or dead organisms, cloudy, yellow to tan
-Purulent - (pus) contains white blood cells and living or dead organisms, thick, creamy yellow, green, or brown
-Bloody purulent
Exudate (Amount)-Scant, Moderate, Heavy - clinical judgment
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Hydration
Daily Fluid Intake vs. Daily Fluid
Loss
Daily Fluid Intake
-Liquid consumed + fluid in foods consumed +
bodily by-product water
Daily Fluid Losses
-Any body fluid
-Kidney use (urine) + GI tract use
(feces) + evaporation from skin + respiration
evaporation
The body does not store water
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Lungs
(350 mL)
Skin
(450 mL)
Excreted Fluids
(1500 mL)
Metabolic Water
(200 mL)
Ingested Foods
(700 mL)
Ingested Fluids
(1400 mL)
Water Gain Water Loss
Adapted from Krause’s Food, Nutrition & Diet Therapy,
11th Edition
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Hydration
Dehydration
Reduction in total body water
-Hyperosmolar (water loss - due to ↑sodium or glucose)
-Hyponatremia (water and sodium loss)
-Electrolyte imbalance (3% body weight)
Long Term Care
-Seen as a sign of poor care
-Results from combination of physiological or disease process
-Not primarily due to lack of access to water
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HydrationBlunted Thirst Mechanisms
Aging
-Homeostasis declines
Infection
Respiratory, GI, GU
Fluid loss or increased fluid need
-Diarrhea, fever, vomiting
Incontinence
-Reduce fluid intake
Fluid restriction
-Renal dialysis
Medications
-Diuretics, sedatives, antipsychotics, tranquilizers
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Cognitive or functional impairment
-Aphasia - unable to communicate effectively
-Dementia or Alzheimer’s disease
Neurological impairment
-Coma or decreased sensorium
Tube feedings
-Dysphagia
-Reduce fluid intake
NPO
-Reduce fluid intake
Use of supplementation
-Thick
-Difficult to swallow
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Hydration
Lab values
-Abnormal glucose, calcium, potassium
-Abnormal serum bicarbonate
-Elevated hemoglobin and hematocrit
-Increased urine specific gravity
-Elevated serum sodium
-Elevated albumin
-Increased Blood Urea-Nitrogen (BUN) level
-Abnormal creatinine
Dehydration screening
-Pale skin
-Sunken eyes
-Red swollen lips
-Swollen and/or dry tongue with
scarlet or magenta hue
-Dry mucous membrane
-Poor skin turgor
-Cachexia
-Bilateral edema
-Muscle wasting
-Calf tenderness
-Reduced urinary output
-Dark urine
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Hydration
Persistent subclinical dehydration
-Anxiety
-Panic attacks
-Agitation
Fluctuation in tissue hydration
-Inattention
-Hallucinations
-Delusions
Severe dehydration
-Somnolence
-Psychosis
-Unconsciousness
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Hydration
Functional Decline of the Renal System
Abnormal Lab Values to Identify Dehydration
-Increased Blood Urea-Nitrogen (BUN) level/3% weight loss
-Abnormal glucose, calcium, potassium
-Abnormal serum bicarbonate
-Abnormal creatinine
-Elevated hemoglobin and hematocrit
-Increased urine specific gravity
-Elevated serum sodium
-Elevated albumin
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Hydration
Moisture-Associated Skin Damage (MASD)
Incontinence-associated dermatitis
-Intertriginous dermatitis
-Periwound moisture-associated dermatitis
-Peristomal moisture-associated dermatitis
Treatment
Use non-alcohol based moisturizers
Establish continence training
-Bowel or bladder training programs
Avoid skin contact with plastic surface to reduce sweating
-Maceration, friction, shear
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Hydration
Incontinence
Urine
-Adequate evaluation to identify whether
reversible causes exist
-Urea converted to ammonia (pH)
Reversible causes
-Urinary tract infection
-Medications
-Confusion
-Polyuria due to glycosuria or hypercalcemia
-Restricted mobility due to restraints
-Managing excessive moisture (sweating)
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Hydration
Incontinence
Bile acids and enzymes in feces
Differentiate between pressure
ulcer and skin breakdown due to
dermatitis
Feces irritate the epidermis and
make the skin more susceptible to
breakdown
Maceration, friction, shear
Fecal impaction
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Hydration
Maintain Skin Integrity
Daily skin inspections-Over bony prominences
-Assess for compromised peripheral circulation
Promote skin hygiene
-Cleanse skin after soiling
-Cleanse skin with saline and skin cleanser
-Avoid alkaline agents which increase skin irritation
-Maintain skin pH 6.8 to avoid bioburden build up and risk of infection
-Use skin protectants or barriers
-Do not massage or rub over bony prominences
Moisture Control
-Use non-alcohol based moisturizers
-Establish continence training bowel or bladder training programs
-Avoid skin contact with plastic surface to reduce sweating
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Hydration
Support Surface (Powered)
Moderate - high risk or resident has a PrU on turning surfaces and the ulcer
Residents unable to assume a variety of positions without bearing weight on the pressure ulcer (manual repositioning)
-Flexion contractures
-Reduce pressure on bony prominences or prevent breakdown from skin-to-skin contact
Additional 10 to 15 ml fluid/kg of body weight
-To prevent dehydration that can occur from the drying effects of these specialty beds
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Hydration
Intervention
Monitor fluid intake and output
-Adult 30 - 35 mL fluid/kg body weight/day
-Minimum of 1500 mL/day
-Additional 10 - 15 mL/kg body weight/day if on an air fluidized bed (due to increase in body
warmth)
Maintain circulation blood volume (reduce hypovolemia - fluid/salt)
Maintain fluid and electrolyte balance
Source: American Medical Directors Association Dehydration and Fluid Maintenance, Clinical Practice Guidelines, Columbia
MD
25© 2013 AMT Education Division
Hydration
Prevention and Management
Education (staff and family members)
-What are barriers to getting water and ice
-What makes it hard to routinely fill water pitchers
Awareness of risk factors
-Early identification of fluid imbalance and acute illness
”Sipper” takes a few sips at a time
-May benefit from being offered frequent small amounts of fluid throughout the day
Dementia resident who is able to drink but forgets
-Use social cues
Identification of MASD risk factor
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Hydration
Fluids With Special Problems
Caffeine (tea and coffee)
-Inhibition of iron
Diet soft drinks
Alcohol
Best Type of Fluid
Un-concentrated
Decaffeinated
Beverage resident will drink
Water is the best fluid for dehydration
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HydrationHydration Strategies
Add cup holders to wheelchairs
Give residents water bottles to carry around facility
Offer beverages from beverage carts
Take fluids on outings and offer frequently
Include beverage break in all activities
Offer glasses of water in dining room while waiting for meals
Have fluids readily available
Encourage fluids
Offer choices
Offer fluids after providing care
Encourage ambulatory residents to drink all fluids offered with meals
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Nutrition
Did You Know
Malnutrition in nursing homes 20% - 54%
Residents
-Having lost 5% of their weight in 30 days (acute)
-10% of their weight in 180 days (chronic) 9.9%
Residents having albumin levels below 3.5 g/dL 6% - 43%
PharMerica Educational Program Sept 14, 2000
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Nutrition
Weight
Admission or readmission
Weekly - first 4 weeks after admission
Monthly (identify changes gain or loss)
Frequent
-Food intake has declined and persisted (more than
a week)
-Evidence of altered nutritional status or fluid and
electrolyte imbalance
-Consider terminally ill
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Weight
Accurate weight
-Time of day
-Clothing
-Scale
-Orthotics/prostheses
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Nutrition
Laboratory Tests
No ne are specific or sensitive enough to warrant serial or repeated
testing or determine a residents nutritional status
Determine whether the test will potentially change the resident’s
diagnosis, management or quality of life
Laboratory test may be affected by age due to:
-Hydration status
-Chronic disease
-Acute illness
-Change in organ function
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Nutrition
Albumin
-Poor indicator of visceral protein status
-Long half life (12-21 days) resident may be malnourished before drop in albumin occurs
-Decrease albumin levels reflect the presence of inflammatory cytokine production
-3.5 - 5.0 g/dL
Prealbumin (transthyretin/thyroxine-binding albumin)
-Short half life (2 - 3 days)
-Subject to the same influences as albumin
-Decreases rapidly when caloric/protein intake decreases
-15.0 – 25.0 mg/dL
HgB A1c
-Glycemic control
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Nutrition
Weight
Reflects the balance between intake and utilization of energy (calorie and protein)
Before instituting a nutritional care plan assess:
-Severity of nutritional compromise
-Probably causes
-Individual’s prognosis
-Projected clinical course
-Resident’s wishes and goals (offer relevant alternatives)
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Nutritional Assessment
Assessment Tool
Establish nutritional risks for all types of individuals
-Oral health status
-Ability to eat
-Proper diet
-Eating patterns
-Chronic diseases affecting appetite
-Medications affecting appetite
Current weight status
Detect under and over nutrition
-Malnutrition Screening Tool
-Short Nutritional Assessment Tool
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Pamela Charney, M.S., R.D. and Ainsley Malone, M.S., R.D.
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Malnutrition
Assessment Tool
Mini-Nutritional Assessment (MNA)
-Risk factors
-Current nutritional status
-Not predictive for future nutritional status
Simplified Nutritional Appetite Questionnaire (SNAQ)
-Appetite
-Satiety
-Taste
-Meal frequency
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Braden Score
At risk: 15 to 18
Moderate risk: 13 to 14
High risk: 10 to 12
Very high risk: 9 or below
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Nutritional AssessmentCare Requirements
Monitor intake of food, tube feeding, TPN
Food intake decreases - offer supplement
Tube feeding or TPN decreases -monitor and ensure infusion of prescribed amount
Evaluate adequacy of prescribed amount
RD evaluates intake of calories and protein if food intake is low
Consider vitamin supplement (especially with elderly or long term care individuals)
Provide assistance with feeding as needed
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Nutritional Assessment
Care Requirements
Baseline labs
Dietitian evaluates and
recommends intake goals
Supplements are provided, intake
counted and recorded
Provide support with eating
Time meals, encourage family to
feed
Encourage favorite food and
snacks
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Nutritional Assessment
Braden >18
Monitor intake and weight
Dietary Consult
-Usual criteria on admission database
-Intake consistently less than 75%
-Metabolically stressed state (trauma, fever etc.)
Significant weight loss (non fluid related)
2% in 1 week
5% in 1 month
7.5% in 3 months
10% in 6 months
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Nutritional Assessment
Braden <18
Inadequate hydration, protein and/or weight loss
-Complete nutrition assessment
-Meet fluid needs
-Visual assessment
-Follow up weekly
Correct source of poor intake if able
-Food preferences, constipation, illness depression, pain, Medication causing poor appetite
Evaluate need for anabolic agent and/or nutrition support
-BMI <20 change diet to high calorie, high protein
-Add therapeutic multivitamin/minimum supplement
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Date: _________RN-RD Pressure Ulcer Screening Assessment Form
For High Risk Populations (page 1)
Age __ Sex M F Ht __ Dx_______
PMH _____ Risk Associated with Dx/PMH? Yes No
>75y Recent Illness Trauma PEM Immobility
Incontinence High risk comorbidities H/O Pressure Ulcer
Smoking ____ppd Other
Patient Info
Addressograph
AppetiteInadequate intake?
Yes NoUnable to assess
NPO Poor 0-50% Fair 50-80 % Good 80–100%
(Downgrade by 1 level for presence of > Stage 3 or multiple Stage 2 wounds)
Diet & MedicationsRisk Assessed?
Yes (explain) No N/A to
assess
Diet:_ Different than usual diet? P.O.
P.O.+ Supplement P.O.+TF NPO+TF NPO
Tube Type: NG G/PEG PEJ Site Intact: Y N
Food Allergies Meds/Supplements
Weight AssessmentDo Not Use Transfer WeightSignificant IWL?
Yes No
Usual Wt ________ Per patient Per care giverAny IWL in the past 2-3 months?
Actual Wt/Date __/____ With equipment Scale: Standing W/C Bed Lift Edema
BMI __ IBW _ % of IBW ___ % of UBW ___
____ % Wt Loss or Gain over past ____ © 2013 AMT Education Division
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GI Complications?Yes No
Date of last BM: __________ No C/O No BS Diarrhea x ________ N/V x ________ Constipation x __________ Colostomy: Liquid Formed Hard Stool
Skin Areas of Concern?
Yes NoBraden Scale
Score _______
(< 18 = at-risk)
Gross Assessment Only
see CWOCN note for
detailed description of
wound(s).
Total # of Wounds: ___
1. _____________ (Location)
Pressure DTI Surgical Stasis
Intact Skin Foul Odor
Thickness: Partial Full
Drainage: Minimal Moderate Heavy
Wound Bed: Beefy red Pale Dry Moist
Hyper-granulation Slough
Eschar Tunneling Undermining
S/S of Infection
Abnormal Lab Values?Yes No N/APending
Baseline Labs Hypoproteinemia Hypogonadism Date Hyperglycemia Dehydration
ALB BUN Creat GFR
PAB Na K Chol
BS HA1c CRP Testosterone
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Nutritional Assessment
Oral Health Status
60-90% of residents have severe periodontal disease
-Gum recession
-Tooth loss (80%)
-Oral pain
-Mouth ulcers (30%)
-Chewing Abnormalities
-Dry mouth
-Gingivitis
-Periodontal disease
-Ill fitting dentures (50%)
Swallowing Abnormalities (Dysphagia)
-Disease of the oropharynx and esophagus
-Dementia
-Stroke
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Key Nutrients
Calories
Resident with PrUs or at-risk for
developement
-25 - 35 kcals/kg body weight/day*
By consuming enough calories,
“spares” the use of protein for energy
-30 calories/kg (15 calories/pound) prevent
protein breakdown in non-obese
Nelms, M, Sucher, K, & Long, S. (2007). Nutrition Therapy and
Pathophysiology. Belmont: Thomson Brooks.
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Key Nutrients
Protein
Building block for repair
-Angiogenesis
-Collagen synthesis
-Granulation tissue
-Epidermal cell proliferation
-Tensile strength
-Resistance to infection
RDA
-0.8 g/kg body weight
-Stress 1.2 to 1.5 g/kg body weight
Nelms, M, Sucher, K, & Long, S. (2007). Nutrition Therapy and
Pathophysiology. Belmont: Thomson Brooks.
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Key Micronutrients
Inflammatory
-Macrophages, neutrophils, blood
clotting, vasodilatation
-Vitamins and amino acids: A, K,
Bromelain
Proliferative
-Angiogenesis, fibroblasts,
collagen deposition
-Vitamins and minerals A, B6, C,
Cu, Fe, Mg, Zn
Remodeling
-Collagen maturation,
stabilization, scar tissue mature
-Vitamin and minerals C, Cu, Fe, Zn
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Key Micronutrients
Vitamin A
Facilitates macrophage entry into the wound and enhances angiogenesis
Antagonizes inhibitory affects of glucocorticoids (corticosteroids)
Stimulates fibroplasia to increase collagen synthesis
5000 - 25000 International Units (IU) X 10 days
Vitamin C (Ascorbic acid)
Not stored in the body
Enhances leukocyte, macrophage activation, fibroblast, collagen synthesis
Depressed levels found in elderly, smokers, and certain cancers
75g/day females and 90 mg/day males
Supplementation 500 - 1000 mg/day for 2 weeks if deficiency suspected
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Key Nutrients
Vitamin E
Scar formation – conflicting reports
Adversely affects vitamin A benefits
May interfere with the healing of
some types of wounds
Vitamin K
Co-factor for coagulation
Monitor prothrombin times (PT)
rations (INR)
Antibiotics may limit vitamin K
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Key Nutrients
L-Arginine
Immune stimulant for lymphocytes
Stimulates release of insulin-like growth factor-I (IGF-I)
Precursor to proline hydroxyproline collagen
Therapeutic dose to promote healing is ~9 g/day
Copper
10 days till depletion
Formation of red blood cells
Vitamin C + copper = elastin production
900 μg/d
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Key Nutrients
Zinc
Increased demand during collagen and protein synthesis
RDA
-11 - 15 mg/males (elemental zinc)
-8 - 12 mg/females (elemental zinc)
-Limit 40 mg/day
Zinc Sulfate 110 - 220 mg (23% elemental zinc)
Supplementation with 25 - 50 mg elemental zinc/day x 2 weeks
-Stage III - IV pressure ulcer
D/C in 6 weeks - may impair copper absorption
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Nutrition
Current evidence does not definitively support any specific dietary supplement unless the resident has a specific vitamin or mineral deficiency
Multivitamins may be given
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Nutrition
Severity of weight loss
Severe weight loss
≥10% in 6 months
≥ 7.5% in 3 months
≥ 5% in one month
≥ 2% in one week
Walker G ed. Pocket Source for Nutritional
Assessment, 6th ed. Waterloo IA
Malnutrition
Deficiency, excess or imbalance of
energy, protein or other nutrients causing
adverse effects on body form, function
and clinical outcomes
-Primary or secondary
-Due to increased total protein turnover
-Rapid loss of lean body mass
Undernutrition
Form of malnutrition in which
inadequate nutrition results from lack of
food or failure of the body to absorb or
assimilate nutrients properly
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Malnutrition
Marasmus
Develops over months
Primarily due to low intake (energy)
Muscle wasting
Edema not prominent
Weight loss prominent
Albumin usually normal
Mortality low
Kwashiorkor
Develops over weeks
Due to stress combined with low intake
of protein
Superficially appears well nourished
Edema characteristic
Weight loss may be absent
Albumin low
Mortality high
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Anorexia and Cachexia
Anorexia
Loss of appetite/loss of interest in
seeking and consuming food
-A psychiatric eating disorder
-Physical - low body weight,
-Psychological - image distortion
-Emotional - depression
-Behavioral - obsessive fear of gaining weight
Immediate weight gain, especially
with those who have particularly
serious conditions that may require
hospitalization
Cachexia
Loss of appetite in someone who
is not actively trying to lose weight
-Insidious loss of weight, muscle atrophy,
fatigue, weakness
-Directly related to inflammatory states
-Rheumatoid arthritis, AIDS, chronic renal
failure, COPD
Resistance to hypercoloric feeding
Tx dependent of diagnosis of
underlying
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Lean Body Mass
Body Mass Index
Sarcopenia
Underweight and overweight
-Same nutritional risks
Diagnostic tool for both obesity
and protein-energy malnutrition
<16 = severe underweight
-16 - 18 = underweight
-19 - 24 = normal
-25 - 30 = grade I obesity (mild)
-31 - 40 = grade II obesity (moderate)
>40 = grade III obesity (severe)
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Lean Body Mass (LBM)
Tube Feeding
-7.5% - 40.1% of resident population
≈20% LBM loss
-Decreased healing, weakness, increased infection,
thinning of the skin, mortality increased by 30%
≥30% LBM loss
-Too weak to sit, PrUs develop, pneumonia, wound
healing ceases, mortality increased by 50%
BMI
-Height and weight
≤18.5 kg/m2 - underweight
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Lean Body Mass
Muscle Mass Decrease
↓energy requirements decline
↓ protein reserves during
periods of stress
↓ total body water increases
chances of dehydration
↑ distribution volume of fat-
soluble drugs
Elimination of fat-soluble drugs
is delayed
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Age 25 Age 70
Lean Body Mass
Creatine Height Index (%)
Marker for skeletal muscle mass
-Creatine (degradation product) formed in active muscle at a constant rate in proportion to
the muscle mass of a individual
-Decreases (protein depletion)
-Amount of creatine excreted in a 24 hour period divided by the amount of creatine
excreted by a normal healthy individual of the same height and sex
>80% = normal protein
-60% - 80% = moderate protein depletion
<60% = severe protein depletion
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Wound Healing Food for Thought
In Conclusion
Nutrition plays an essential role in wound healing and wound care
practices, and nutritional support needs to be considered a fundamental
part of wound management
By combining knowledge of the wound healing process together with best
practice provision of nutrition, healthcare professionals can help decrease
the morbidity and mortality associated with chronic wounds as well as
reducing their cost and impact
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I ain’t afraid of no wound
Thank YouQuestions?
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References
Barbul A, Lazarou SA, Efron DT, et al: Arginine enhances wound healing and lymphocytes immune responses in humans. Surgery 1990; 108:331-337.
Black JM, Edsberg LE, Baharestani MM, LangemoD, Goldber M, McNicholL, Cuddigan J. Pressure Ulcers :Avoidable or Unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Management 2011;57(2): 24-37.
Campbell, S. Maintaining hydration status in elderly persons: problems and solutions. Support Line, 1992;7-10.
CMS Guidance for 483.25 (i)-Nutrition F(325)
Demling RH, Nutrition, Anabolism and the Wound Healing Progress: An overview. Eplasty, 2009;65-93.
Dorner B. Posthauer ME, Thomas D, The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper; 2009.
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References
Illinois Council on Long Term Care. Water: The Fountain of Life. Retrieved
March 30, 2007, http://www.nursinghome.org/fam/fam_018.html
Kieselhorts K J, Skates J, & Prichett E, (2005). American Dietetic
Association: The Standards of practice in nutrition care and updated
standards of professional performance. Journal of the American Dietetic
Association, 105(4), 641-645.
Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly.
Chest 2003;124(1):324-336.
Malnutrition And Dehydration Plague Nursing Home Residents Lack Of
Adequately Trained Personnel Largely To Blame. The Commonwealth Fund
June 7, 2000.
Mentes J, (2006). Oral Hydration in Older Adults. American Journal of
Nursing, 106(6), 40-49.
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References
Nelms, M, Sucher, K, & Long, S. (2007). Nutrition Therapy and
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© 2013 AMT Education Division64